Clinical presentation A pregnant woman (third trimester) presented with intense abdominal pain, nausea and myalgia. The patient was obese (body mass index 38) and was being treated for high blood pressure, hyperuricemia and hypothyroidism. She had chronic renal deficiency related to focal segmental glomerular sclerosis requiring dialysis. The physical examination at admission revealed a fever of 39°C and an acute abdomen with abdominal guarding in the right upper quadrant without hepatomegaly or splenomegaly. There were no clinical signs of pre-eclampsia. Fetal ultrasound and a Doppler of the umbilical vessels were normal. Laboratory tests showed normal liver and liver function (total protein 95%, alanine transaminase (ALT), aspartate transaminase (AST), total bilirubin normal). The white cell count was 10×109/l (90% neutrophils), with a normal platelet count. Blood, urine and vaginal cultures were negative. Abdominal ultrasound revealed isolated thickening of the gallbladder wall without cholelithiasis. Empirical antibiotic treatment was begun with intravenous amoxicillin. Six days later, the patient's condition had worsened with increased abdominal pain, persistent fever and liver test abnormalities (AST–ALT 6N). However, bilirubin, hepatic synthesis tests, as well as leucocyte and platelet counts were still normal. A caesarean section followed by coelioscopy was decided. Coelioscopy revealed a liver with numerous necrotic spots (see figure 1).
Question What is the diagnosis?
- ABDOMINAL PAIN
- LIVER DISEASE IN PREGNANCY
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Acute herpetic perihepatitis
Herpes virus serology was positive for IgM, and PCR herpes was positive for herpes simplex virus 2 (HSV-2) in blood. Pathological examination of the surgical liver biopsy obtained from the lesions showed necrotic herpetic hepatitis limited to the subcapsular liver parenchyma. This was confirmed by specific immunostaining (hepatocytic nuclear herpes virus inclusions). The patient was treated successfully with acyclovir.
Fulminant acute febrile liver failure related to herpes virus infection is a well-defined cause of acute liver failure in the third trimester of pregnancy.1–3 The most frequent presentation is fulminant hepatic necrosis with fever (39°C–40°C), severe neutropenia, thrombopenia with AST and ALT between 100-fold and 1000-fold above normal and normal bilirubinemia. The prognosis is poor and the diagnosis is frequently made at the postmortem examination (58%)2 ,3 but can be improved by rapid acyclovir therapy. Our patient had an unusual presentation of HSV-2 primoinfection without fulminant hepatitis and limited to a herpetic perihepatitis with capsulitis associated with intense abdominal pain and guarding. Abdominal pain has been described in patients (50%–75%) with fulminant hepatitis.1 ,2 A recent report described a pregnant woman with febrile acute abdomen and abnormal liver tests suggesting peritonitis. Coelioscopy revealed a spotty liver; liver histology and virological tests confirmed herpes viral infection.4
These case reports suggest that a diagnosis of herpes should be considered in pregnant women or immunocompromised patients with fever and acute abdominal pain even in the absence of severe acute hepatitis. Early empirical treatment with intravenous acyclovir could prevent fulminant hepatitis in these patients and reduced the high rate of mortality.
The details have been removed from this case report to ensure anonymity.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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